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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603752
Report Date: 09/20/2025
Date Signed: 09/20/2025 01:19:47 PM

Document Has Been Signed on 09/20/2025 01:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:INSPIRED ELDERLY CARE LIVING IIFACILITY NUMBER:
198603752
ADMINISTRATOR/
DIRECTOR:		GALLEGOS, LAURIEFACILITY TYPE:
740
ADDRESS:627 N. JANSEN AVETELEPHONE:
(909) 240-1321
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 6CENSUS: 3DATE:
09/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:29 AM
MET WITH:Orlando Dipon, CaregiverTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Blanca Gonzalez conducted an unannounced required annual inspection visit. LPA was greeted by Caregiver Cherry Dipon and the purpose of the visit was explained. Administrator Laurie Gallegos was contacted by phone.
The facility is licensed to serve six (6) non-ambulatory adults age range 60 and over. Bedrooms #2 and #4 approved for two (2) non-ambulatory each. Bedrooms #1 and #3 approved for one (1) non-ambulatory each. Garage not approved as a living area.
The facility is a single-story home in a residential neighborhood of San Dimas. The home consists of living room, dining area, kitchen, family room, four (4) resident bedrooms, two (2) bathrooms, front and back yards.
LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
The front and backyard are well maintained and there are no pools or large bodies of water. There is a shaded area located in the backyard with sufficient seating for residents in care. Passageways and exits are free of obstruction.
The water temperature was tested in bathroom #1 in the hallway and measured 111.2 degrees F and bathroom #2 water temperature measured 111.3 degrees F, which is within the required 105 degrees F - 120 degrees F. LPA observed grab bars and non-skid mats in both the bathrooms.

continued on LIC 809C
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 09/20/2025 01:19 PM - It Cannot Be Edited


Created By: Blanca Gonzalez On 09/20/2025 at 12:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: INSPIRED ELDERLY CARE LIVING II
FACILITY NUMBER: 198603752

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
87202(a)(2)
(a) All facilities shall maintain a fire clearance approved by the city... Prior to accepting or retaining any of the following types of persons, ...(2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of [total 3 persons (R3) physician's report dated 03/10/25 indicated bedridden and the facility fire clearance is not approved for bedridden, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/21/2025
Plan of Correction
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Licensee will develop a plan to either obtain an updated medical assessment for R3 or submit a new LIC 200 signed by Licensee and updated facility sketch to indicate the acceptence of bedridden residents. CCL will request fire inspection once documents are received. Licensee will email LPA a statement of the plan by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Blanca Gonzalez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: INSPIRED ELDERLY CARE LIVING II
FACILITY NUMBER: 198603752
VISIT DATE: 09/20/2025
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Resident bedrooms have all require furniture which includes, for each resident, a bed, a chair, night stand, a lamp, or lights sufficient for reading. Bed linens were clean and in good repair. There is closet space for clothing and other belongings. Hall closet contained extra clean linens.
Interconnected smoke detectors were observed throughout the facility and are operable. There is a carbon monoxide detector located at the entrance of the home and another by the back bedroom. There are two (2) fire extinguishers located in the hallway and near the kitchen. Emergency drills are conducted quarterly, the last was conducted 07/04/25.
Kitchen appliances are clean and were operating at the time of the visit. Sharps are locked in a kitchen drawer and are inaccessible to residents. Cleaning supplies and disinfectants are locked under the sink and are inaccessible to the residents. Sufficient supply of 2 days perishable and 7 days non-perishable foods were observed.
Fireplace located in the living room is inaccessible with a covered screen. Dining room, family room and living room are clean and free of obstructions and have sufficient seating for residents in care.
Medications are centrally stored in a cabinet in the dining room. Medications are documented properly and given as prescribed. First Aid kit was fully stocked with current manual.
Three (3) resident and three (3) staff files were reviewed and were observed to contain required documentation. R#3 physician’s report indicates bedridden, facility does not have fire clearance for bedridden.

Per California Code of Regulations, Title 22, an immediate $500 Civil Penalty was assessed for Fire Clearance.
Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies were cited during today’s visit.

Exit interview conducted and a copy of this report, LIC809D, LIC421IM, and Appeal Rights were provided to Orlando Dipon, caregiver.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Blanca Gonzalez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2025
LIC809 (FAS) - (06/04)
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